Last January, Dr Sean Maskey found hundreds of children who had attended the Child and Adolescent Mental Health Services (Camhs) in South Kerry had received substandard care, with significant harm caused to 46 children due to the inappropriate prescription of medication.
The treatment of 227 children attending South Kerry Camhs was considered risky. Following publication of the Maskey Report, the Children's Rights Alliance said: “This is one of the most damning reports published on mental health services for children.
"It demonstrates failures at all levels: clinical failure, management failure, oversight failure and administrative failure.
"It’s deeply disturbing that young children were subjected to psychotropic medication — for normal emotional responses — leading to devastating consequences. Children will have lost years of their life because of this treatment.”
The findings were described as “shocking” by the then taoiseach Micheál Martin and “beyond comprehension” by the HSE chief executive.
Article 24 of the Human Rights Convention is clear. “Every child has the right to enjoy the highest possible standard of health, to access health and other related services and to facilities for the treatment of illness and rehabilitation of health.”
Article 42A of the Irish Constitution affirms children's natural and imprescriptible rights and the State's duty to uphold these rights. Children have the right for their best interests to be of paramount consideration where the State seeks to intervene to protect their safety and welfare.
The failure of Kerry Camhs to deliver a safe mental health service was not just a scandal of one unsupervised junior doctor but a scandal of repeated and continuing political failure.
It was an issue local to Kerry but the harming of large numbers of vulnerable young people by State failure was and is a national issue.
One year after the Maskey Report, Kerry Camhs remains in crisis, and one could reasonably ask: where is the leadership to change this?
Dr Sean Maskey’s report was forensic. He noted there was an absence of a consultant clinical lead for Team A, Kerry Camhs. This absence had contributed to the failure to deliver and sustain a high-quality service.
Dr Maskey was clear the service had not implemented many of the recommendations of the Camhs Standard Operating Procedure 2015 or the subsequent Camhs Operational Guidelines in 2019.
Dr Maskey recalled that in July 2018, the whole Camhs team wrote to senior management in the HSE detailing multiple concerns about waiting lists, access to training and development for staff, a fragmented autism diagnosis pathway in Kerry Area A, and limited community resources that would otherwise take cases referred to Camhs.
They raised the issue of safety for the patients, through inadequate clinical resources and training, waiting lists, and access to inpatient beds.
The absence of a clinical lead, the consultant child and adolescent psychiatrist, was a long-standing concern for the group. Dr Maskey, in his evaluation of this concern, noted one of the key contributory factors that led to the harm caused to children was “the absence of a consultant in Team A, as this absence meant there was no regular, effective oversight of junior doctors’ work through formal supervision and frequent joint working with a senior doctor”.
Dr Maskey referred to Vision for Change, where the consultant is the clinical lead as defined by legislation. The absence of a clinical lead means there is no one, in the words of Vision for Change, to “articulate the collective vision of the team and ensure clinical probity”.
Dr Maskey points out that: “Rebuilding trust must be a primary focus of the service in considering how to take forward these recommendations. The children’s' and the parents’ voices have been quiet in this review.
"If the service is to rebuild their trust, children and their families must be involved in the process, rather than experience it as something being done by “they”.
He went on to say the HSE had a lot of work to do to create the conditions that would attract a consultant in South Kerry.
Parents, young people, and community services reading these words from Dr Maskey may have breathed a collective sigh of relief and possibly experienced hope the Government and HSE would try and follow through on the recommendations.
If the main recommendation was to rebuild trust with the employment of a clinical lead as in a consultant psychiatrist in Kerry Camhs Team A, a reasonable expectation would be that every measure would be put in place to source an experienced Camhs consultant who would be supported to work with families, other clinicians in Camhs, community services, GPs, and hospitals.
A real urgency was to turn the service around from one which harms children to become one that children and families might trust to “do no harm”.
Accepting the real and difficult challenge of finding a consultant to lead and rebuild trust in the damaged Kerry service, what measures were put in place for an internal transfer of a consultant to take on the task?
What measures did the Government take to support the HSE to enable an experienced consultant psychiatrist to take a post in Kerry?
Were there any incentives offered for a transfer to Kerry from one of the well-resourced in psychiatry CHO areas?
There are many retired Camhs consultant psychiatrists who engage in private practice in Ireland and England. Were any of these doctors approached about the possibility of leading the Kerry team in its time of crisis?
We don’t know. The HSE retreated to its old veil of secrecy. The silence from the Government was deafening. Having seen what was done during the Covid pandemic, I do not believe it is beyond the ability of the Government to create the conditions for the employment of a consultant psychiatrist on an emergency basis to turn Kerry Camhs around.
What did emerge is that in Kerry south, initial Camhs assessments of children who may have waited up to two years on a waiting list, are now conducted by telehealth services, with the consultant psychiatrist joining the session from Doha.
"This means the first meeting that the child and family have with the Camhs consultant psychiatrist is online, with the family in Kerry and the consultant in Doha."
This assessment meeting is crucially important as it is the first point of contact with the clinical lead. This meeting can be a very anxious time for children and years of experience has taught me that particularly young children and teenagers are often understandably anxious and suspicious of the professionals in the room.
Establishing therapeutic links and forming relationships at that first meeting is important. Sitting together with the weight of a problem for a child and family is an often daunting and challenging piece of work for clinicians, carers, and children but it is often the “sitting together with the problem” that allows it to become manageable. Doing this successfully from Doha is impossible.
One of the aims of an initial Camhs assessment is to gather background information to try and understand what has been going on in the child or adolescent’s life.
An initial assessment also seeks to ensure Camhs is the right service for the child or adolescent and that they and their parent(s)/carers are happy to attend the service.
The initial assessment will cover a range of areas including personal information, social history, family history, education, physical health, lifestyle factors, risk assessments, strengths and protective factors and the views of the child or adolescent and their parent(s) on the current situation.
Parents and children are asked to share deeply personal information and often this is the place where family tensions are highlighted.
Clinicians in the room are trained to listen for the “unsaid” and to observe family power dynamics. Well-trained clinicians are sensitive to who might try controlling the session.
"Because of the complexity of family life and the complexities inherent in the developmental mental health of children it is impossible to offer a quality Camhs assessment online.
Telehealth assessments in Camhs is not good practice. Research in the UK has found telemedicine poses risks to children and young people’s safety, for example staff missing cues or issues that would have been picked up face-to-face, as well as failure to assess unseen risks within the home environment.
HSE Camhs Operational Guidelines 2019 says ”children and adolescents should be empowered to participate meaningfully in the design, implementation, delivery, and evaluation of mental health services”
Previously, children in Kerry Camhs have spoken of the lack of consultation with them around their assessment and treatment. Were they consulted about the use of telehealth as part of their Camhs assessment?
This poor assessment practice is currently taking place against a background of continuing failure at all levels. The core recommendation of the Maskey Report that trust must be restored appears to be abandoned.
The children and families in Kerry who need to access Camhs have suffered enough. Their past and present treatment does not meet the requirements of Article 24 of the Human Rights Convention or any other reasonable measure. "
The clinicians, as in the psychologists, social workers, nurses, occupational therapists, and administrative staff who have stayed working in Kerry Camhs despite its poor reputation and no leadership or psychiatry support, need to be acknowledged for their work and supported with clinical leadership that is in the room, and not halfway across the world in Doha.
This can only come about with strong political leadership at Government level. Why would any experienced consultant put themselves in the disaster that is Kerry Camhs, if they were not confident the Government was serious about having this situation addressed.
The ongoing potentially dangerous situation in Kerry Camhs would indicate the Government is more concerned with cosmetic rather than real change.
Article originally published: https://www.irishexaminer.com/opinion/commentanalysis/arid-41051102.html
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